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Please look at the below table to see which sections of the claim form are NRMA Travel Insurance, c/o Cover-More Claims Department, Private Bag 913 North 

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How do I make a claim with NRMA?

You can make your claim with NRMA in 3 simple steps: 1

Fill out the claim form

Please look at the below table to see which sections of the claim form a re needed for your claim and what pages they can be fou nd on. I am claiming for:I need to fill out:On pages: A medical cost I incurred overseasPart 1, Part 2, Medical form 2-3, 9-10 Additional transport or accommodation costs I incurred on my trip Part 1, Part 3, Medical form is needed if the event was an illness/injury

2-3, 4, 9-10

The cost of amending/cancelling my tripPart 1, Part 42-3, 5-6 - due to illnessMedical form9-10 - and I have a travel agentTravel agent form11-12 Lost/stolen/damaged luggage or moneyPart 1, Part 52-3, 7 Clothing and toiletries I purchased due to a luggage delayPart 1, Part 62-3, 8

Rental car insurance excess

Part 1, Part 72-3, 8

Something not listed abovePart 1, Part 82-3, 8

If you have more than one reason to claim E.g. lost luggage at the start of your trip and a medical bill at the end), please fi ll out all relevant parts of the form. 2

Provide all relevant documentation

Each section of the claim form has a checklist of the documents we requi re to support your claim If you can't provide any of the documents we request, please include a letter explaining why

We accept documents in a foreign language

3 Send us your claimclaims_processing@covermore.com.au (you can send up to 10mb of attachments) NRMA Travel Insurance, c/o Cover-More Claims Department, Private Bag 913

North Sydney NSW 2059

(registered or express post recommended)

02 9202 8098 (scanning and emailing your claim is recommended over faxing)

What happens next?• If you submit your claim via email, you will receive a confirmation emai l, and then our response to your claim within 10 business days. If you submit your claim via post or fax, we will contact you with our r esponse to your claim within 10 business days.

Please do not staple or glue the pages of this claim form or any included documents together before submitting to our oce.© March 2016 Cover-More Insurance Services Pty Ltd Page 1

Part 1: General information - All questions in this section must be answered d. Your declaration

I/we declare that:

all statements and particulars stated on this form and all documents sub mitted are true and correct. I/we will cooperate fully with the insurers in the assessment of my claim. I/we have not withheld any material information connected with this clai m that will inhibit the insurer's ability to make a fair and reasonable assessment of my claim. I/we acknowledge that my personal information may be disclosed to, and o btained from, certain other parties including the Insurance Reference Services database, other insurers and government agencies. I/we assign to the insurer all rights of recovery/salvage against any pe rson or organisation and will cooperate to secure such rights. I/we have read and understood the Privacy Notice on page 13. you may send the personal information included on this form and related documents overseas to assess investigate and pay my claim. I understand that this information may not be subject to the same level of Privacy as is offered by the Australian Privacy

Regime and that I will

not be able to seek redress under the Privacy Act 1988 in the overseas j urisdiction. where I/we provide information, including sensitive information, about o ther individuals, that I/we have informed them (or their parent, guardian, executor or Power of Attorney) of the personal information being provid ed and the contents of the Privacy Notice and have obtained their consent to providing the information.

Signature of claimant(s)

Date

Your policy number

a. Your information Title

Given name(s) Surname Date of birth

Occupation

Mobile phone (or best other contact) Email address

Postal address

Suburb State Postcode

b. Payment

If your claim is approved we will deposit your settlement into your nominated bank account below (we cannot make payments to a credit card).

We prefer to pay successful claims directly into your bank account as it is faster and safer.

Name of bank

Branch

Account holder name

BSB number Account number

(If you do not complete above payment details, we will post you a chequ e which may take up to 5 additional days.) Please ensure that the bank account details you provide to us are correc t. We will not be liable for any loss that you suffer a s a result of payment(s) made to an incorrect bank account because the details you have supplied were incorrect. If you are unsure of your bank account details, please contact your bank or financial institution for assistance. c. ABN holders

Are you registered for GST purposes?

Yes - Fill out your ABN and answer all questions under c. ABN Holders

No - Proceed to d. Your declaration

ABN Have you claimed or are you entitled to claim an Input Tax Credit (ITC) in respect to the GST paid on the insurance policy under which this claim i s being made? Yes No If Yes, what percentage of the GST did you claim or are you entitled to claim? (If the GST paid and your ITC entitlement are the same amount, the answ er to this question is 100%) WARNING: We are committed to investigating claims to avoid passing the c osts of dishonest and fraudulent claims on to you. We t ry to conduct investigations quickly and with minimal disruption. Fraud will be report ed to the police. Unsure? Contact your policy provider to obtain a copy of the Certificate of Insurance.

For assistance

call: 1300 135 640 © March 2016 Cover-More Insurance Services Pty Ltd

Page 2

REQUIRED DOCUMENTATION: FOR OVERSEAS MEDICAL AND DENTAL CLAIMS:

Original itinerary

Certificate of Insurance

Medical reports from the treating overseas medical provider which confirm the diagnosis.

All invoices and receipts.

If the claim is due to a dental condition, we require written confirmation from the treating dentist that the treatment was not caused by or related to the deterioration and/or decay of teeth or associated tissue. The Medical Authority (page 9) completed by the person whose state of health caused the claim or Executor of the Estate if applicable. The Medical Certificate (page 9) completed by your usual medical practitioner. Please note: If you are unable to provide this or don't have a usual G.P., we may have to request Medicare records which can delay the processing of your claim. f. Claim details

Date of incident

Time AM/PM

Country

Town

Whereabouts/location

Please provide an explanation of your claim and why you are claiming (Please include a letter if more space is required). If the claim was caused by a health condition/dental problem/death please answer the following questions: Person whose state of health/dental problems/death caused the claim

Given name(s)

Surname

Relationship of that person to you

Has the illness/injury occurred before?

Yes

No If Yes, advise

the condition. Were you/was the person treated as a hospital inpatient overseas? Yes No

Date admitted

Time admitted

AM/PM

Date discharged

Time discharged

AM/PM Did you/the person contact the 24 hour emergency assistance team? Yes No

Please list each bill/receipt separately:

Amount charged

Name of doctor, dentist, pharmacy, hospital or provider Date of treatment, consultation etc. (include currency) Paid?

E.g. Dr T Smith, New York Medical Centre

1 9 1 1 1 4

USD$180.00

Yes No

/ / Yes No / / Yes No / / Yes No / / Yes No / / Yes No / / Yes No e. Credit card information

Name on credit cardName of financial institution

REQUIRED DOCUMENTATION:

If you answered Yes to purchasing your travel arrangements on your credi t card, you will need to supply: the front page of your credit card statement which shows the cardholder' s name as well as the last 8 digits of your credit card number. the page of your credit card statement which shows the purchase of your travel arrangements. (Non-relevant transactions may be blanked out).

Some credit cards may provide limited travel insurance cover in some circumstances. Did you use your credit c

ard to purchase your travel? (e.g. flights, accommodation, tours?) Yes

No If Yes, please complete the following:

Card type:

Visa

Mastercard

Diners

Amex

Card level:

Gold

Platinum

Other (please specify)

© March 2016 Cover-More Insurance Services Pty Ltd

Page 3

Please complete this section if you are claiming for expenses incurred as a result of an unforeseen event.

E.g. Accommodation and transport

expenses.

1. Please provide a full description of why the additional expenses were incurred.

Description of costAmount claimedDescription of costAmount claimed

1. E.g. FlightAUD$2005.

2.6. 3.7. 4.8.

2. If the above event had not occurred, what were your original plans for the same period?

Original expected planExpected costOriginal expected planExpected cost

1. E.g. FlightAUD$1005.

2.6. 3.7. 4.8.

3. Were your original plans above pre-paid?

Yes No

Partly paid

4. If your original plans were pre-paid, did you receive a refund? Yes No If Yes, please advise the amount

5. If your claim is due to travel delay please advise when you were due to depart and when you actually departed.

When were you due to depart?

When did you actually depart?

Date

Time Date Time

AM/PM AM/PM

Mode of transport

Transport provider name

REQUIRED DOCUMENTATION:

Original itinerary

Certificate of Insurance

All invoices and receipts.

If your claim is due to travel delay:

You will need to supply a letter from the transport provider that confirms the length and reason for the delay as well as any compensation offered.

If caused by a medical condition:

If the expenses were incurred due to someone's health, you will need to supply a medical report from the treating overseas medical practitioner confirming the nature of the illness or injury that gave rise to your claim. The Medical Certificate (page 9) completed by your usual medical practitioner for claims due to a medical condition, illness or death (i.e. not an injury). The Medical Authority (page 9) completed by the patient whose health has caused the claim or the Executor of the Estate for claims due to a medical condition, illness or death (i.e. not an injury). © March 2016 Cover-More Insurance Services Pty Ltd

Page 4

Please provide consent by signing below if you would like your travel agent to be able to provide and receive information, including sensitive

information, relating to this claim.

Your travel agent's name

Name of the travel agency

Signature of policyholder(s)

Date

1. Were all of your travel arrangements booked by a travel agent?

Yes - You do not need to fill out the following. Instead, please have yo ur travel agent complete the 'Agent form' on page 11. No - Please fill out the table following for any arrangements that you b ooked yourself. If any of your travel arrangements were booked by a travel agent, please have them fill out page 11.

You only need to complete the following for travel arrangements being claimed that were not arranged by a travel agent.

Your policy covers you for amendment or cancellation, whichever is the l ess (subject to policy limits and the terms and conditions of the Product Disclosure Statement). Firstly you need to work out how much it would c ost you to amend your journey (e.g. to travel at a later date) compared to the non-refundable amount you won't be able to get back if you cancel the journey. In most cases it is more cost effective to amend your journey rather than cancel it. If you have not made any changes to your travel p lans yet as a result of a potential claim under this section, please phone us and we will guide you.

2. On what date did you cancel/amend your journey? / /

3. Can you travel on different dates?

Yes No If No, please explain the reason why you have not amended the jou rney.

REQUIRED DOCUMENTATION:

Original itinerary

Certificate of Insurance

A copy of your original itemised invoice for your travel arrangements. If due to someone's health (medical condition, injury or death): The Medical Certificate (page 9) completed by the usual medical practitioner. The Medical Authority (page 9) completed by the person whose state of health caused the claim or the Executor of the Estate. Additionally, if the claim is due to someone's death you will need to provide a full copy of the Death Certificate (not an extract) that states the cause of death. *Please note that you can obtain the travel information required below from your travel agent or supplier directly. International flights documentation (for any international flights) • A copy of the airline's fare sheet/rules (showing the fare conditions). • N.B.: Please check the conditions as many airlines have waivers E.g. in the case that a passenger or their relative dies, you may be able to claim a refund from the airline with the submission of a medical or death certificate. This must be applied for first before submitting a claim. Domestic flights documentation (for any domestic flights) • Confirm if the ticket has been changed to travel at a later date. If the date hasn't been changed, there is a 12 month credit allowance that is available for use through the airline. If the customer is unable to use the credit, the customer will need to obtain confirmation that the credit has been cancelled before claiming for it through their travel insurance policy. • Jetstar: Confirm if the ticket has been changed to travel at a later date. If any amounts are being held in credit with the airline, the customer will need to obtain confirmation that the credit has been cancelled before claiming for it through their travel insurance policy. • Qantas: Identify what the specific conditions are for the Qantas fare. E.g. "Red E deal", "fully flexible" etc and confirm if the ticket has been changed to travel at a later date or advise if any amounts are being held in credit with the airline. If the customer is unable to use the credit, they will need to obtain confirmation that the credit has been cancelled before claiming for it through their travel insurance policy. Land arrangements documentation (for any land bookings) • We require a copy of the providers booking conditions showing the published cancellation penalties. This is usually shown in the back of the relevant brochures. • If the booking conditions do not specify exactly what cancellation fees apply (E.g. cancellation fees may be up to 100%) then we require written confirmation from the wholesaler confirming how much you are to be refunded.

Cruise documentation (for any cruises)

• We require a copy of the providers booking conditions showing the published cancellation penalties. This is usually shown in the brochures. • We also need a breakdown of any tax component (I.e. port taxes) that should be refundable. © March 2016 Cover-More Insurance Services Pty Ltd

Page 5

column for any amended arrangements

Please fill out this column for any cancelled

$If the trip was cancelled outright prior to departure what would it have cost to amend the trip to different dates (rather than cancel outright)? A.

Amount paid

Fully refundable

by the airline

B. Amount

refunded by supplier

Amount claimable

(A minus B) $0 $500

Flights

(excluding taxes) taxes

Accommodation

Packages

Other (I.e. car hire, rail passes, transfers etc.)

E.g. Flight$2500$500$2000=

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